International Journal of Otolaryngology and Head & Neck Surgery, 2019, 8, 71-79

http://www.scirp.org/journal/ijohns
ISSN Online: 2168-5460
ISSN Print: 2168-5452

Myringoplasty Modification Adopted to

Overcome Some Long and Short Term
Surgical Issues

Raja Salman Khurshid, Nisar Hussain Madni

MMABM Hospital, Anantnag, India

How to cite this paper: Khurshid, R.S. and Abstract

Madni, N.H. (2019) Myringoplasty Mod-
ification Adopted to Overcome Some Long Objective/Hypothesis: We have tried to present some of our concerns re-
and Short Term Surgical Issues. Interna- garding the usually adopted surgical techniques of Myringoplasty with their
tional Journal of Otolaryngology and Head
possible solutions. Also we have tried to present digital recordings of pre and
& Neck Surgery, 8, 71-79.
https://doi.org/10.4236/ijohns.2019.82008 post-operative findings in reference cases, which have been provided rarely in
available literature. Pre- and post-operative pictures and videos of two repre-
Received: January 7, 2019 sentative cases are attached. Study design: This prospective study was carried
Accepted: March 1, 2019
Published: March 4, 2019
out in MMABM hospital. Forty six (46) ears, 37 patients underwent tympa-
noplasty by the modified dual grafting technique and the results were ana-
Copyright © 2019 by author(s) and lysed. Results: Objectives of tympanic membrane repair, dry ear, closure of
Scientific Research Publishing Inc.
AB gap, and stoppage of tinnitus if any, were achieved in all cases. Small re-
This work is licensed under the Creative
Commons Attribution International sidual perforations which healed over time were seen in two cases in cartilage
License (CC BY 4.0). deficient areas. Conclusion: Dual graft modified techniques served as an ef-
http://creativecommons.org/licenses/by/4.0/ fective alternative myringoplasty technique.
Open Access
Keywords
Myringoplasty Modifications, Cartilage Tympanoplasty, Dual Grafting
Myringoplasty

1. Introduction
Myringoplasty techniques have already reached a pinnacle with all the described
techniques producing excellent results [1] [2] [3]. Stillit is one of those surgical
procedures where no one follows a routine course. All the surgeons we have seen
operating use their own modifications and techniques which better suit them.
And also surgeons keep on modifying and varying their techniques with each
case. Taking heart from this we have tried to present some of our concerns re-

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R. S. Khurshid, N. H. Madni

garding the usually adopted surgical techniques of Myringoplasty with their

possible solutions. Also we have tried to present digital recordings of pre and
post-operative findings in reference cases, which have been provided rarely in
available literature. Pre and post operative pictures of two representative cases
are shown.
Surgical issues of concern:
1) Neo-tympanum may be thin/transparent/weak vulnerable to trauma (baro-
trauma mostly) or may perforate easily in case of any re-infection [2] [3].
2) Neo-tympanum may be thin/weak vulnerable to form retraction pockets
which in long term may lead to atelectasis or cholesteatoma formation [3].
3) Re-perforation/retraction/cholesteatoma formation because of any reason
leads to loss of faith and trust in surgeons and the surgical procedure itself, de-
spite all the efforts of explaining the pathogenesis, especially in a closed setup
and rural communities [4].
4) Placement of graft in the usual surgical techniques does not give much le-
verage to the surgeon as graft needs to be properly supported with an assured
tucking in under the tympanic membrane annulus.
Modification:
Instead of one, we have used two grafts in this technique. The temporalis fas-
cia graft is harvested as usual. Then a tragal cartilage 1 cm × 1 cm piece with pe-
richondrium at least on one side intact is harvested. The bulkier ends of the car-
tilage are trimmed with a surgical blade. The cartilage could be made as trim as
needed. Then the cartilage is placed to fill in the perforation. The cartilage is
placed below the level of neck of the malleus taking care not to block the aera-
tion/ventilation channels of middle ear which are all known to exist above this
level. Again care is taken that the cartilage size should not be more than the ac-
tual size of perforation, and it just fits in the perforation. If the cartilage does not
fit in, it is divided into multiples pieces to cover the area of the perforation. Then
the temporalis fascia graft is placed and tucked under the tympanic membrane
remnant as usual followed by gel foam packing of EAC. Size of the perforation
guides about the size of cartilage to be used. However, we have not favoured any
particular size of perforation for using the cartilage graft.
Efforts to overcome the concern:
1) Placement of cartilage with or without temporalis facia graft gives a stiff-
ness and strength to the neo-tympanum which may not perforate that easily in
case of any trauma (like barotrauma).
2) Strong and stout neo-tympanum is more likely to be resistant to from re-
traction pockets, thus decreasing the chances of atelectasis post operatively or
even cholesteatoma formation.
3) Theoretically placement of the cartilage graft along-with the perichondrium
overcomes the concerns of placing a graft which may or may not survive for long
due to doubtful nutritional support.
4) Placement of temporalis fascia graft in a case where a cartilage support is
provided becomes much easier, and intra-operatively the graft tucks to tympanic

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 R. S. Khurshid, N. H. Madni

membrane closely and provides a lot of margin to the surgeon.

5) The healing time and neo-tympanum formation time may change with
theoretical prospect of quicker and more assured healing when stouter cartilage
graft with perichondrium is used.
Concerns regarding the modified technique:
1) Thick and stout neo-tympanum decreases the chances of air-bone gap clo-
sure.
2) The ventilation channels of middle ear may get blocked with the cartilage
pieces resulting in post-operative retraction pockets.
3) Prolongation of operating time as two grafts needs to be harvested.
4) An opaque neo-tympanum may be of concern in the follow-up of these pa-
tients.
Commentary on concerns:
Use of cartilage makes the neo-tympanum opaque and stout. Despite a theo-
retical concern of affecting the air bone gap closure chances, it has been seen
that the effect on AB gap is statistically insignificant, or that the patients are
unaware of any conductive deafness [5] [6]. Use of cartilage slicer to thin out the
bulkier portions of the graft may further obtund these concerns. However, in
this study cartilage slicer has not been used.
Care is taken to place the cartilage pieces below the level of ossicles preferably
below the level of neck of malleus. This theoretically reduces the chances of
block of ventilation channels and reduces the incidence of post-operative retrac-
tion pockets. This is supported by the fact that the ventilation channels in mid-
dle ear lie in the epitympanum or at the level of junction of mesotympanum and
epitympanum [7].
As the placement of graft takes much less time when the cartilage is already in
place, the overall operating time is not significantly affected.
Use of such a technique further strengthens the belief that tympanoplas-
ty/myringoplasty is a high output surgical procedure with a universal success
rate and excellent surgical outcome despite any modifications adopted.

2. Material & Methods

This study was carried out in MMABM hospital. Forty six (46) ears, 37 patients
underwent tympanoplasty by the modified dual grafting technique. Patients in
the teens, third and fourth decades were included. All the patients included had
CSOM of inactive mucosal type with a safe disease and with perforations of all
sizes. This ensured that most of the cases could be done under local anaesthesia
and uniformity of the procedure could be expected. Only 03 patients were of age
less than 15 yrs and had to be operated under general anaesthesia. Also all the
cases were operated by one surgeon for uniformity. Cholesteatoma or patients
with unsafe CSOM type where not included in this series. The results were ana-
lysed and compared with the cases done previously in the same hospital using
the conventional single graft technique. The results were also analysed for com-

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R. S. Khurshid, N. H. Madni

parison with the published data in various journals that could be retrieved by
PubMed/Medline search. The features that were compared pre and post opera-
tively included perforation closure rates, pure tone audiograms, and patient sa-
tisfaction score.

3. Results/Observations
1) Age of the patients ranged from 11 to 48. Most of the patients of this age
group were selected to allow for patient cooperation and cases to be done under
local anaesthesia. Only 3 cases who were less than 15 years were operated under
general anaesthesia.
2) Out of the 37 patients operated, 26 were females and 11 were males. In 9
patients both ears were operated. This is depicted in Table 1 below.
All these patients belonged to rural areas or to small towns, and had long
standing chronic otitis media with stable perforations on examination. This is
mentioned in Table 2 below.
3) All the patients had inactive mucosal CSOM with central or subtotal perfo-
ration. Patients with attic perforations, mastoid involvement, or cholesteatoma
were dealt with separately and were not part of this study. Most of the ears had
subtotal to total perforation, and the rest had central perforations of various siz-
es.
4) Preoperative audiograms revealed conductive deafness ranging from 24 db
to 51 db. Preoperative CT scans had been ordered in two patients only, revealing
no mastoid cell coalescence. All other patients had a preoperative mastoid radi-
ograph done to rule out any coalescence.
5) Ossicular erosions were seen in four (04) ears preoperatively and were ma-
naged with incus repositioning in 3 cases and PORP prosthesis in one case.
6) Postoperative complications: Postoperative recovery was uneventful in all
except in one patient who got injury (slap) on 12th postop day and had a rup-
tured TM. But fortunately it healed in 2 weeks’ time and he recovered complete-
ly. In the postoperative period, 7 patients complained of headache with normal
ENT examination. All these patients were managed as primary headaches and
responded well to low dose Nortriptyline.
7) The perforation closure assessed at 3 weeks revealed small residual perfora-
tions in two cases in anteroinferior and anterosuperior quadrants respectively.

Table 1. Distribution of patients.

Number of ear operated Number of patients Males Females

46 37 11 26

Table 2. Classification of perforations on preoperative examination.

Number of Total perforation Subtotal perforation Central perforations

ears operated preoperatively preoperatively of various sizes

46 23 12 11

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 R. S. Khurshid, N. H. Madni

The perforation sites coincided with the cartilage deficient sites in these cases.
These perforations healed completely after 3 months in one case and at 6
months in another. Thus, we had a perforation closure rate of 100% in these
cases.
8) Pre- (Figure 1 & Figure 2) and post-operative (Figure 3 & Figure 4) pic-
tures are shown in two representative cases.
9) Postoperative audiograms revealed reduction of air-bone gap to 12 to 25 db
with all the patients unaware of any conductive deafness.
Figure 5 and Figure 6 compare the preoperative audiogram with postopera-
tive status in a representative case operated employing modified dual graft tech-
nique.

Figure 1. Case 1: Pre-operative.

Figure 2. Case 2: Pre-operative.

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R. S. Khurshid, N. H. Madni

Figure 3. Case 1: Post-operative.

Figure 4. Case 2: Post-operative.

Figure 5. Preoperative audiogram in reference case.

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 R. S. Khurshid, N. H. Madni

Figure 6. Postoperative audiogram in the same case.

4. Discussion
The use of cartilage for tympanic membrane repair is extensively reported in li-
terature [8] [9] and the benefits of long-term graft survival, low recurrence and
infection rates have been described, particularly decreased development of tym-
panic membrane retraction pockets over time [10] [11]. Most of the authors
have reported excellent functional results for small and large perforations [12]
[13]. Cartilage tympanoplasty comprises a heterogeneous group of techniques
including the cartilage-perichondrium composite graft, diced cartilage, butterfly
techniques, and palisade cartilage tympanoplasty [14]. Tos M. reviewed 23 dif-
ferent cartilage tympanoplasty methods and grouped them into six categories
from A to F [15]. The method adopted by us in this report could be classified a
modified category F cartriage tympanoplasty described by Tos.
The modified dual graft myringoplasty provides all the benefits that cartilage
tympanoplasty is known for (like decreased chances of retraction pockets and
higher rates of perforation closure), besides the added intra-operative manoeu-
vrability benefits for the surgeon. The graft placement and tucking is much easi-
er with this technique. This advantage may be utilised positively by younger ear
surgeons in the earlier periods of training. The maintenance of middle ear space
does not seem to be an issue since the ventilation channels of middle ear space
are maintained by ensuring that the cartilage graft is placed in the lower meso-
tympanum.
All the objectives of tympanoplasty, namely dry ear, well-formed and stout
tympanic membrane, free of retraction pockets, reversal of conductive deafness,
and with the result full confidence in the procedure are achieved with this tech-
nique. However, as long as this technique is not replicated by other surgeons the
apprehensions over the possible persistent conductive deafness and failure to
heal will remain. This report is an attempt to convince the fellow ear surgeons
about the multitude of possible techniques that can be adopted with confidence,

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R. S. Khurshid, N. H. Madni

particularly in view of the digital recordings as a proof.

5. Conclusion
The repair of tympanic membrane, being one of the commonest ENT proce-
dures, has varied techniques with the basic principles unaltered in each. The
procedure adopted can be modified with enough confidence by individual de-
pending on what works best for each.

Conflicts of Interest
The authors declare no conflicts of interest regarding the publication of this pa-
per.

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